<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/10/2021
Date Signed: 05/17/2021 11:39:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SISKIYOU SPRINGS SENIOR LIVING COMMUNITYFACILITY NUMBER:
475002711
ADMINISTRATOR:BRAUER, ELAINEFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: 62DATE:
05/10/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elaine Brauer (Admin).TIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/10/2021 at 1:00p.m. Licensing Program Analyst (LPA) Misty Valencia, Licensing Program Manager (LPM) Kevin Mknelly, Regional office Manager (ROM) Alycia Berryman CCL Nurse Christina Wong and Myra Cunanan Program Clinical Consultant Supervisor, conducted virtual office meeting with Elaine Brauer (Admin).

Today’s office meeting was done via Google Duo, due to COVID-19 precautionary measures. During today’s virtual office meeting, the following was to review the following discussed from meeting conducted 5/7/2021:

· Facility wearing N95 masks while in the facility while there are covid positives
· Facility identifying a staffing shortage
· Facility providing covid info as soon as possible
· Referrals that have been provided CHPCA referral 4/30/21, HAI referral and support

following up on referrals;
· Staff Roster and schedule (LIC 500)
· Date staff from Aya will start to supplement staffing to work solely with COVID positives
· Date Infectious control is scheduled to come to Siskiyou Springs
· Confirmation that the paperwork was submitted for CalMAT to LPHD (Shelly)
· Date Northstar will come to the facility to assist with mitigation plan and infectious control
· Submit funding paperwork to LPA (Misty)
· Updated Line List every time new staff and residents are tested and when the results are received.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1